Designated Crisis Responder (DCR) Training

Transcription

1 Designated Crisis Responder (DCR) Training Division of Behavioral Health & Recovery Behavioral Health Administration Department of Social & Health Services

2 Who are we? What are we going to present? What are adult learning principles? What would you like to know?

3 Training Objectives Implementation Process The Plan Applicable RCWs DSM-5 Substance Use Disorders (SUD) Criteria American Society of Addiction Medicine (ASAM) Criteria SUD Presentation & Risk SUD Treatment Continuum EMTALA & CFR 42 Case Discussion & Practice

4 HB 1713: Ricky s Law How did we get here? HB 1713 was passed during the 2016 Legislative Session Integrates detention and commitment processes for mental health and substance use disorders (SUD) by incorporating SUD into RCW and RCW 71.34

5 RCW Emergency detention of persons with mental disorders or substance use disorders (1) When a designated crisis responder receives information alleging that a person, as the result of a mental disorder, presents an imminent likelihood of serious harm, or is in imminent danger because of being gravely disabled, after investigation and evaluation of the specific facts alleged and of the reliability and credibility of the person or persons providing the information if any, the designated crisis responder may take such person, or cause by oral or written order such person to be taken into emergency custody in an evaluation and treatment facility for not more than seventy-two hours as described in RCW (2) When a designated crisis responder receives information alleging that a person, as the result of substance use disorder, presents an imminent likelihood of serious harm, or is in imminent danger because of being gravely disabled, after investigation and evaluation of the specific facts alleged and of the reliability and credibility of the person or persons providing the information if any, the designated crisis responder may take the person, or cause by oral or written order the person to be taken, into emergency custody in a secure detoxification facility or approved substance use disorder treatment program for not more than seventy-two hours as described in RCW , if a secure detoxification facility or approved substance use disorder treatment program is available and has adequate space for the person.

6 HB 1713: Ricky s Law The two primary tasks of the Department (DSHS): Create Designated Crisis Responders (DCRs) Ensure that at least one 16 bed secure detoxification facility is operational by April 1, 2018 and a second facility is operational by April 1, 2019

7 Implementation Who is involved? Legislature changes to law, budget decisions DSHS implement, write WAC, provide training, develop policy DMHP/DCR Teams use ITA process, determine team practice, develop policy BHOs/ASOs/Counties facilitate access to resources, contract with providers, develop policy Courts interpret law, set legal precedence SUD Treatment Providers provide treatment and ongoing assessment, accept referrals, determine rule-outs

8 Implementation Signed by the Governor April 18, 2016 Facility design and development Commerce funds for site development Operational funds in current Governor s budget Process for funding treatment Incorporation into DMHP Protocols WAC development Website with further information

9 Facility Design ASAM 3.7 Level of Care Medically Monitored Intensive Inpatient Services Physician available to assess inperson within 24 hours of admission Nursing assessment on admission Medication prescription and monitoring Coordination of necessary services and discharge planning Planned regimen of professionally directed evaluation and treatment services E&T Level of Care Examination and medical evaluation within 24 hours by a licensed physician, advanced registered nurse practitioner, or physician assistant certified Psychosocial evaluation by a mental health professional Development of an initial treatment plan Consideration of less restrictive alternative treatment Availability of seclusion and restraint

10 Changes to the RCWs Joel s Law and Parent Initiated Treatment (PIT) will apply to involuntary treatment evaluations for SUD All provisions of RCW & will apply to SUD, except: Single Bed Certifications Loss of firearm rights Assisted Outpatient Treatment

11 RCW Detention or judicial commitment of persons with developmental disabilities, impaired by chronic alcoholism or drug abuse, or suffering from dementia. Persons who are developmentally disabled, impaired by chronic alcoholism or drug abuse, or suffering from dementia shall not be detained for evaluation and treatment or judicially committed solely by reason of that condition unless such condition causes a person to be gravely disabled or as a result of a mental disorder such condition exists that constitutes a likelihood of serious harm: Provided however, That persons who are developmentally disabled, impaired by chronic alcoholism or drug abuse, or suffering from dementia and who otherwise meet the criteria for detention or judicial commitment are not ineligible for detention or commitment based on this condition alone.

12 DCR Assessment Mental Health Substance Use Meets Criteria for Detention Does Not Meet Criteria for Detention Meets Criteria for Detention and needs Detox Meets Criteria for Detention but not Detox Does Not Meet Criteria for Detention Aggressive Assaultive Acute Medical Needs Care Needs (Fall Risk, ADLs, Can t Transfer) E&T Level of Care Aggressive Assaultive Acute Medical Needs (Detox or Medical Issue) Care Needs (Fall Risk, ADLs, Can t Transfer) ASAM 3.7 Level of Care E&T Bed Available Single Bed Cert Available No Bed Available Voluntary Inpatient Appropriate Less Restrictive Secure Detox Bed Not Available Hospital Treatment Secure Detox Bed Available Voluntary Detox Residential/ Outpatient Assess for Mental Health Detention under RCW Complete No-Bed Report/Hospital Hold under EMTALA/ Discharge

13 Rule Out vs Assessment 1 st Decision = Do they meet criteria for detention? The Biggest Change: Substance use (including BAL and positive toxicology screens) is now collected information, rather than a reason to push back a referral) Regional practice may vary, and will be likely based on current relationships and expectations with local partners Secure Withdrawal Management & Stabilization is an additional resource for those who meet criteria for detention Dangerous behavior that occurs only when someone is intoxicated should not be discounted ( drunkicidal, etc)

14 Why is this important? Implementation is currently in process This is going to be bumpy Secure Withdrawal Management & Stabilization is an additional resource 70.96A 70.96B (Pilot Project) Incorporating SUD into and addresses the emergent nature of the risks posed by SUD

15 Values & Bias Clarification We all have biases Societal stigma related to substances Everyone has history Value and Bias Exercise No right or wrong answers Exercise is designed to acknowledge bias, and values Participate as you are comfortable

16 The Person: Module 1 Holistic Assessments & Determining Risk Biopsychosocial Assessment DSM-V Substance Use Disorders Criteria ASAM Dimensions & Risk Rating

17 Holistic Assessments ITA INVESTIGATIONS Value of ITA investigations No tool that is a required part of ITA assessment Weigh all factors No one factor that causes an individual to be detained DSM-V Criteria for SUD & ASAM DIMENSIONS DCRs are not required to use these tools for diagnosis or assessment Familiarity with language Assist in communication with other professionals and the court Risk is defined differently than for ITA investigations

18 DMHPs/DCRs & Risk Imminent Non-Emergent Other Risk Considerations Conduct a holistic investigation, taking into consideration all risk, history of behavior, and current presentation If it contributes to a likelihood of serious harm or grave disability, it should factor into the determination to detain or not

19 MH & SUD Risk Positive for methamphetamines; upset at loss of job and girlfriend; threatening to kill self; had gun to head when police arrived at home Positive for methamphetamines; digging at her face due to fears of bugs under her skin; large open wound almost puncturing her cheek Positive for opiates, threatening to kill self on the anniversary of partner s death next month Intoxicated and driving History of Major Depressive Disorder with Psychosis; upset at loss of job and girlfriend; threatening to kill self; had gun to head when police arrived at home Diagnosis of schizophrenia; digging at her face due to fears of tracking devices under her skin; large open wound almost puncturing her cheek Major Depressive Disorder, threatening to kill self on the anniversary of partner s death next month Manic and driving

20 Biopsychosocial Assessment Biopsychosocial Assessment History of the Present Episode Mental Health Status Physical Presentation Psychiatric History Medical History Substance Use; History of Use Review of Systems Personal History/Social History Family History Cultural Factors Spiritual Factors Protective & Risk Factors Suicide attempt? Severity? Requesting help? Oriented? Insight? Active psychosis? Disheveled? Agitated? Well groomed? Previous hospitalizations? General health? Acute medical issues? Significant previous use? Previous treatment? Enrolled in mental health services? Has a CCO? Involved in drug court? Isolated? Friends and support network? Lives with family? Childhood chaos/trauma? Family members with substance use or mental health disorder? History of suicide? Isolated within larger culture? Specific cultural beliefs or coping mechanisms? Religious beliefs a source of strength, guilt, connection?

21 Group Discussion & Exercise: Risk & Protective Factors

22 Why is this important? Petition Writing! SYMPTOMS BEHAVIORS RISK This process is exactly the same as for mental health detentions, with the inclusion of symptoms and presentation associated with substance use

23 Diagnosis & ITA Assessment A specific diagnosis is not required to determine criteria for detention, however: DCRs must be able to recognize symptoms and presentation indicating primary substance use rather than mental health, to make a determination regarding detention then use that evidence in the petition A provisional diagnosis for inclusion in detention paperwork and transportation authorization forms will ease the process Unspecified [Substance of Use]-Related Disorder Unspecified Other (or Unknown) Substance-Related Disorder

24 DSM-V SUD Criteria A pathological pattern of behaviors related to use of a substance Abuse & Dependence replaced with Substance Use Disorder Impaired Control (Criteria 1-4) Social Impairment (Criteria 5-7) Risky Use (Criteria 8-9) Pharmacological (Criteria 10-11)

25 Impaired Control 1-4 Use in larger amounts over a longer period of time than intended Persistent, unsuccessful attempts to cut down or discontinue use Great deal of time spent obtaining, using, or recovering Craving What does this look like? I ve been using since I was 13. I wanted to quit a bunch of times. I went to treatment a couple times, but it didn t work. I need to get more every day. When I was in jail, I had dreams about using.

26 Social Impairment 5-7 Failure to fulfill major role obligations Continued use despite problems Giving up or decreasing other activities What does this look like? I was going to school, but I can t do that anymore. My mom takes care of my kids now. I know I should stop, I went to jail a few weeks ago.

27 Risky Use 8-9 Use in situations that are physically hazardous Continued use despite knowing use causes problems What does this look like? I drive a school bus/forklift/my children to school, and I need to use in the morning before I leave the house. My husband is upset with me and talking about divorce if I don t get help, but I can t quit right now.

28 Pharmacological Tolerance - Requiring a markedly increased dose to achieve the desired effect, or receiving a markedly reduced effect when the usual dose is consumed Withdrawal - A syndrome that occurs when blood or tissue concentrations of a substance decline after prolonged heavy use of a substance What does this look like? It takes a lot more to get high than it used to. If I go a couple of days without a drink, I get the shakes.

29 ASAM American Society of Addiction Medicine (ASAM) Criteria An attempt at unbundling services Contrasts Adult and Adolescent services The language used in assessment and placement for SUD Used Statewide Not perfect, but can be helpful in your conversations Not a training in ASAM assessment and placement

30 ASAM Assessment

31 ASAM Patient Assessment Each patient is assessed in each of the six dimensions, defined as Risk Rating 0 Minimal/None 1 Mild 2 Moderate 3 Significant 4 Severe

32 What is the Risk rating? RISK IS MULTIDIMENSIONAL AND BIOPSYCHOSOCIAL IN NATURE RISK RELATES TO THE INDIVIDUAL S HISTORY RISK IS EVALUATED IN TERMS OF THE INDIVIDUAL S CURRENT STATUS RISK INVOLVES ASSESSMENT FROM A NON-PROBLEMATIC BASELINE OBSERVATION TO AN ESCALATION OF PROBLEMS RISK ASSESSMENT MUST INTEGRATE HISTORY, ONGOING LIFE SITUATIONS, AND CURRENT PRESENTATION RISK ASSESSMENTS ARE EVALUATED FOR EACH OF THE SIX ASAM DIMENSIONS

33 Dimension 1 Acute Intoxication and/or Withdrawal Potential

34 Dimension 1: Mild The patient demonstrates adequate ability to tolerate and cope with withdrawal discomfort. Mild to moderate intoxication or signs and symptoms interfere with daily functioning, but do not pose an imminent danger to self or others.

35 Dimension 1: Moderate The patient has some difficulty tolerating and coping with withdrawal discomfort. Intoxication may be severe, but responds to support and treatment sufficiently that the patient does not pose an imminent danger to self or others. Moderate signs and symptoms, with moderate risk of severe withdrawal (e.g. as a continuation of withdrawal management at other levels of service, or in the presence of heavy alcohol or sedative-hypnotic use with minimal seizure risk, or many signs and symptoms of opioid or stimulant withdrawal).

36 Dimension 1: Significant The patient demonstrates poor ability to tolerate and cope with withdrawal discomfort. Severe signs and symptoms of intoxication indicate that the patient may pose an imminent danger to self or others, and intoxication has not abated at less intensive levels of service. There are severe signs and symptoms of withdrawal, or risk of severe but manageable withdrawal; or withdrawal is worsening despite withdrawal management at a less intensive level of care (eg, as continuation of withdrawal management at other levels of service, or in the presence of opioid withdrawal with cravings and impulsive behaviors).

37 Dimension 1: Severe The patient is incapacitated, with severe signs and symptoms. Severe withdrawal presents danger, such as seizures. Continued use poses an imminent threat to life (eg, liver failure, GI bleeding, or fetal death).

38 Dimension 2 Biomedical Conditions & Complications

39 Dimension 2: Mild The patient demonstrates adequate ability to tolerate and cope with physical discomfort. Mild to moderate signs or symptoms (such as mild to moderate pain) interfere with daily functioning.

40 Dimension 2: Moderate The patient has some difficulty tolerating and coping with physical problems and has other biomedical problems. These problems may interfere with recovery and mental health treatment. The patient neglects to care for serious biomedical problems. Acute, non-life-threatening medical signs and symptoms (such as acute episodes of chronic, distracting pain, or signs of malnutrition or electrolyte balance) are present.

41 Dimension 2: Significant The patient demonstrates poor ability to tolerate and cope with physical problems, and/or his or her general health condition is poor. The patient has serious medical problems, which he or she neglects during outpatient or intensive outpatient treatment. Severe medical problems (such as severe pain requiring medication, or brittle diabetes) are present but stable.

42 Dimension 2: Severe The patient is incapacitated, with severe medical problems (such as extreme pain, uncontrolled diabetes, GI bleeding, or infection requiring IV antibiotics).

43 Dimension 3 Emotional, Behavioral, or Cognitive Conditions & Complications

44 Dimension 3: Mild The patient has a diagnosed mental health disorder that requires intervention, but does not significantly interfere with addiction treatment.

45 Dimension 3: Moderate Patients are of two types. The first exhibits this level of impairment only during acute decompensation. The second demonstrates this level of decompensation at baseline. This risk rating implies chronic mental illness, with symptoms and disability that cause significant interference with addiction treatment, but do not constitute an immediate threat to safety and do not prevent independent functioning.

46 Dimension 3: Significant Patients are of two types; the first exhibits this level of impairment only during acute decompensation and the second demonstrates this level of decompensation at baseline. This risk rating is characterized by severe psychiatric symptomology, disability, and impulsivity, but the patient has sufficient control that he or she does not require involuntary confinement.

47 Dimension 3: Severe Patients have severe psychiatric symptomology, disability, and impulsivity, and require involuntary confinement.

48 Group Exercise ASAM Risk Rating

49 The Person: Module 2 Substance/Medication Induced Mental Disorders Medical Complications

50 Substance/Medication Induced Mental Disorders Intoxication Withdrawal

51 Criteria A. The disorder represents a clinically significant symptomatic presentation of a relevant mental disorder B. There is evidence from the history, physical examination, or laboratory findings of both of the following: A. The disorder developed during or within 1 month of a substance intoxication or withdrawal, or taking a medication B. The involved substance/medication is capable of producing the mental disorder C. The disorder is not better explained by an independent mental disorder D. The disorder does not occur exclusively during delirium E. The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

52 Alcohol Intoxication Recent ingestion of alcohol Blackouts Presentation varies depending on amount of alcohol consumed over what period of time Significant suicide risk during intoxication and alcohol-induced depressive and bipolar disorders Withdrawal May develop within a few hours to a few days following cessation of heavy, prolonged use Typically lasts 3-7 days Post-acute withdrawal may last up to 2 years Alcohol withdrawal delirium (more likely if a medical condition is present)

53 Cannabis Intoxication May develop within a few minutes if smoked, or several hours if consumed orally Due to fat solubility, symptoms may persist for up to 24 hours Withdrawal May develop within a week of cessation of daily/almost daily use lasting at least a few months Typically does not require medical treatment but makes relapse/continued use likely

54 Hallucinogens Intoxication Depending on the specific substance, may last a few minutes to a few hours If snorted, smoked, or injected may have rapid onset May result in a temporary increase in suicidality Undetectable Rapid onset and resolution of symptoms? Rule out mental health diagnosis Look for clues in the individual s statements Withdrawal No withdrawal Hallucinogen Persisting Perception Disorder

55 Inhalants Intoxication Recent intended or unintended short-term, highdose exposure an inhalant substance Symptoms clear within a few minutes to a few hours results in recurring brief episodes Death due to cardiac arrhythmia or cardiac arrest Intoxication symptoms without a corresponding tox screen Withdrawal No withdrawal

56 Opioids Intoxication Periods of depression are common with chronic intoxication Individuals may demonstrate inattention to the environment to the point of ignoring harmful events Withdrawal Symptoms can develop within several minutes to several days following cessation of use for several weeks or longer Administration of an opioid antagonist will immediately begin withdrawal

57 Benzodiazepines Intoxication May present very similarly to alcohol intoxication Intoxication may occur at very low doses with if cognitive impairment, TBI, or delirium is present Withdrawal Symptoms may develop within several hours to within several weeks of cessation of use Timeframes depend on half-life of medication Medications with a longer half-life can result in life threatening delirium

58 Stimulants Intoxication Depressant effects are uncommon, and seen only with chronic, highdose use Symptoms may be masked or affected by sedatives taken at the same time to manage unpleasant symptoms Withdrawal Symptoms develop within a few hours to several days following cessation of use Anhedonia and craving are often present but not diagnostic criteria

59 Group Exercise Imminent Risk Intoxication & Withdrawal

60 General Medical Complications Trauma Diabetes Liver disorders Edema Deep Vein Thrombosis (DVT) Renal Failure (not directly associated) Lung diseases Hepatitis HIV/AIDS Heart conditions Cancer Dementia MRSA Endocarditis

61 Delirium Tremens (DTs) A rapid onset of confusion usually caused by withdrawal from alcohol (benzodiazepines) When it occurs, it is often three days into the withdrawal symptoms and lasts for two to three days. People may also see or hear things other people do not. Physical effects may include shaking, shivering, irregular heart rate, and sweating Occasionally, a very high body temperature or seizures may result in death Severe anxiety and feelings of imminent death are common DT symptoms 50% of people with AUD experience DT s (1-4% mortality)

62 DT Warning Signs High and long-term use Poor hygiene, weigh loss, gnarly appearance, dehydration History of DT s, seizures High BAL and appearance of normal functioning Spiders, snakes, bugs Visual hallucinations Medications: Benzodiazepines (diazepam, lorazepam, chlordiazepoxide, and oxazepam)

63 Alcoholic Neuropathy The exact cause of alcoholic neuropathy is unknown. It likely includes both a direct poisoning of the nerve by the alcohol and the effect of poor nutrition associated with alcoholism Up to half of long-term heavy alcohol users develop this condition Symptoms: Numbness in the arms and legs Abnormal sensations, such as "pins and needles Painful sensations in the arms and legs Muscle weakness Muscle cramps or muscle aches Heat intolerance, especially after exercise Problems urinating (incontinence) Constipation Diarrhea

64 Wernicke-Korsakoff Syndrome Wernicke s encephalopathy severe thiamine deficiency (acute phase) Korsakoff s psychosis is the neurologic consequence of the encephalopathy (chronic symptomology) Causes problems learning new information, inability to remember recent events and long-term memory gaps Memory problems may be strikingly severe while other thinking and social skills are relatively unaffected Individuals may seem able to carry on a coherent conversation, but moments later be unable to recall that the conversation took place or to whom they spoke Confabulate," or make up, information they can't remember They are not "lying" but may actually believe their invented explanations Staggering and stumbling, lack of coordination, and abnormal involuntary eye movements.

65 Medical complications: Heroin (Opiates) Constipation. Insomnia Lung complications (including various types of pneumonia and tuberculosis) Sexual dysfunction Irregular menstrual cycles Collapsed veins Bacterial infections Abscesses Infection of heart lining and valves Arthritis and other rheumatologic problems Liver and kidney disease Infectious disease (e.g., HIV, hepatitis B and C)

66 Medical complications: Methamphetamine Psychosis, including: paranoia hallucinations repetitive motor activity Changes in brain structure and function Deficits in thinking and motor skills Increased distractibility Memory loss Aggressive or violent behavior Mood disturbances Severe dental problems Weight loss Pulmonary Arterial Hypertension

67 The System: Module 3 Logistics of Substance Use Treatment Withdrawal Management & SUD Treatment Medication Assisted Treatment Involuntary Secure Detox Facilities Less Restrictive Facilitating Admission EMTALA 42 CFR

68 DCR Assessment Mental Health Substance Use Meets Criteria for Detention Does Not Meet Criteria for Detention Meets Criteria for Detention and needs Detox Meets Criteria for Detention but not Detox Does Not Meet Criteria for Detention Aggressive Assaultive Acute Medical Needs Care Needs (Fall Risk, ADLs, Can t Transfer) E&T Level of Care Aggressive Assaultive Acute Medical Needs (Detox or Medical Issue) Care Needs (Fall Risk, ADLs, Can t Transfer) ASAM 3.7 Level of Care E&T Bed Available Single Bed Cert Available No Bed Available Voluntary Inpatient Appropriate Less Restrictive Secure Detox Bed Not Available Hospital Treatment Secure Detox Bed Available Voluntary Detox Residential/ Outpatient Assess for Mental Health Detention under RCW Complete No-Bed Report/Hospital Hold under EMTALA/ Discharge

69 ASAM Levels of Care for Treatment Services and Withdrawal Management Level 3.1 Facilities Thunderbird, ABHS, Seadrunar Level 3.5 Facilities Lifeline, Olalla, Seadrunar, Sundown M, Thunderbird Level 1 Ambulatory Withdrawal Management (w/o onsite monitoring) Level 2 Ambulatory Withdrawal Management (w/ extended onsite monitoring) Level 3.2 Clinically Managed Residential Withdrawal Management Level 4 Medically Managed Intensive Inpatient Level 3.7 Medically Monitored Inpatient Withdrawal Management Patient Care Needs: Mild withdrawal w/ daily or less than daily outpatient supervision Patient Care Needs: Moderate withdrawal management and support, has supportive family or living situation at night Patient Care Needs: Moderate withdrawal but needs access to 24 hour support to complete and increase likelihood of completion Patient Care Needs: Severe withdrawal and needs 24 hour nursing care and physician visits as necessary Patient Care Needs: Severe unstable withdrawal and needs 24 hour nursing care and daily physician visits

70 MAT Options Methadone: liquid, long lasting, sustains dependency, higher potential for some addictive behaviors, some diversion (mostly pill form), lethal Suboxone: pill or film, long lasting, sustains dependency, more potential for diversion, potential for less addictive behavior, not lethal (by itself) Vivitrol: monthly injection, no dependency, no diversion, not lethal, FDA approved for alcohol & opioid treatment

71 MU Receptor Activation

72 Addiction or Dependent? Dependence- the brain has adapted to the effects of a substance, requiring regular and consistent and increasing amounts of the substance to create the same effect. Addiction- dependency with maladaptive behavior to access the substance, taking more than prescribed, by alternative methods, and significant preoccupations to find, acquire and use the substance through any means necessary.

73 Role of MAT and Therapy Stabilization Recognition of difference between dependent and addiction Each MAT affects different parts of the brain Type of MAT utilization dependent on patient choice All MAT s require prescription Stress/Conflict and its affect on relapse Trauma, PTS, TBI Co-occurring mental health diagnoses

74 Brain function

75 Possible Referral Options Refer to Office Based Opioid Treatment (OBOT) Refer to Opioid Treatment Program (OTP) Newly developing Hub and Spoke (six project sites through out Washington) Part of new State Targeted Response (Opioid-STR Grant)

76 Naloxone Harm reduction Available in nasal spray and injectable Currently available, through PDO grant and STR Grant (ADAI) Distributed through Syringe Exchange programs Available by co-prescribing at a pharmacy and may be covered by insurance to get a kit for a family member

77 Involuntary Bed Available! Phone Screening Present clinical picture Facilitate medical screening Labs Arrange transportation No Bed Available Single Bed Certification unavailable until 7/1/26 Complete a No-Bed Report Follow procedures developed in collaboration with your BHO or ASO Consider detention due to mental health factors under RCW

78 Group Exercise Phone Screening

79 Voluntary Look for an available bed Contracted facilities Local resources See resource list in packet materials Screen with potential receiving facility Present clinical picture Facilitate medical screening Labs Arrange transportation

80 Exercise Less Restrictive Recommendations

81 EMTALA Enacted by Congress in 1986 Emergency Medical Treatment & Labor Act: ensures public access to emergency services regardless of ability to pay Section 1867: Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented

82 EMTALA Why is this important? There is an affirmative obligation on the part of the hospital to provide a medical screening examination to determine whether an "emergency medical condition" exists There are restrictions on transfers of persons who exhibit an "emergency medical condition" or are in active labor, which restrictions may or may not be limited to transfers made for economic reasons The hospital has an affirmative duty to institute treatment if an "emergency medical condition" does exist This includes the hospital s responsibility to provide treatment if there is no bed available

83 When can a patient be transferred to another facility? A transfer to another facility before the patient has become stable can only take place if it is an "appropriate transfer" under the statute A transfer after the patient has become stable is permitted and is not restricted by the statute in any way Of course, the question of whether the patient has become stable is sure to generate factual and medical issues when litigation ensues, so the hospital would be careful here A transfer of a patient who is not experiencing an "emergency medical condition" is permitted and is not restricted by the statute in any way In other words, and speaking a bit loosely, a patient may be freely transferred either before the emergency condition arises or after it has been resolved, and may only be transferred under a defined set of circumstances while the condition exists

84 Why is this important? Secure Withdrawal Management and Stabilization Facilities are able to accept transfers from ERs ER must have receiving facility acceptance of transfer (not allowed to dump) ER not allowed to transfer unstable individuals Benzodiazepines (some issues) Alcohol withdrawal (the longer the hold the bigger the issue) DT s, Seizures GOMER

85 Code of Federal Regulations (CFR) Medical emergencies. (a) General Rule. Under the procedures required by paragraph (c) of this section, patient identifying information may be disclosed to medical personnel who have a need for information about a patient for the purpose of treating a condition which poses an immediate threat to the health of any individual and which requires immediate medical intervention.

86 HIPAA The HIPAA Privacy Rule permits a covered entity to disclose PHI, including psychotherapy notes, when the covered entity has a good faith belief that the disclosure: (1) is necessary to prevent or lessen a serious and imminent threat to the health or safety of the patient or others and (2) is to a person(s) reasonably able to prevent or lessen the threat. This may include, depending on the circumstances, disclosure to law enforcement, family members, the target of the threat, or others who the covered entity has a good faith belief can mitigate the threat. The disclosure also must be consistent with applicable law and standards of ethical conduct. See 45 CFR (j)(1)(i).

87 The System: Module 4 Petition Writing Stages of Change & Motivational Interviewing SUD in the ITA System Review

88 Communication How do we communicate and document risk? With the court? With providers? With the SWMS facilities? With referral sources? Determining risk and detainability (or not) is a DMHP/DCR strength Use ASAM and DSM language to assist in communication

89 Why is this important? Petition Writing! SYMPTOMS BEHAVIORS RISK This process is exactly the same as for mental health detentions, with the inclusion of symptoms and presentation associated with substance use

90 Petitions for SUD Detention Write Legibly How did the individual come to your attention? List and explain the observed signs and symptoms of substance use Link the presentation/symptoms to the likelihood of harm or grave disability Provide any history supporting the decision to detain Explain why less restrictive options are not appropriate Note consultation with collateral witnesses and the ED physician if appropriate Complete petition with a clear positive statement Based on the WADMHP DMHP Academy training

91 Declarations & Affidavits Suggestions for documents in support of a petition for detention or revocation: The declarant/affiant should identify themselves and their relationship to the individual Describe their direct knowledge of the individual s substance use Describe their direct knowledge of the individual s risk Concluding with a clear statement that they feel the respondent needs withdrawal management and SUD treatment There is no need for the declarant/affiant to make a statement referencing that the individual needs involuntary treatment Based on the WADMHP DMHP Academy training

92 Biopsychosocial Assessment Biopsychosocial Assessment History of the Present Episode Mental Health Status Physical Presentation Psychiatric History Medical History Substance Use; History of Use Review of Systems Personal History/Social History Family History Cultural Factors Spiritual Factors Protective & Risk Factors Suicide attempt? Severity? Requesting help? Oriented? Insight? Active psychosis? Disheveled? Agitated? Well groomed? Previous hospitalizations? General health? Acute medical issues? Significant previous use? Previous treatment? Enrolled in mental health services? Has a CCO? Involved in drug court? Isolated? Friends and support network? Lives with family? Childhood chaos/trauma? Family members with substance use or mental health disorder? History of suicide? Isolated within larger culture? Specific cultural beliefs or coping mechanisms? Religious beliefs a source of strength, guilt, connection?

93 Practice Petition Writing

94 Stages of Change

95 Motivational Interviewing William Miller & Stephen Rollnik MI is a method that works on facilitating and engaging intrinsic motivation within a client in order to change Directive Resolving Ambivalence ( 5 chairs, Exercise)

96 Motivational Interviewing Listen more than you speak Resist the urge to fix the problem TM2 = Tell me more Find the discrepancy, point it out Open-ended questions Summary - if you can t agree Confusion is a resourceful state Be an advocate for their work don t do their work

97 SUD in the ITA System Challenges Our own biases Perception of ITA Limited resources Strengths Maintain hope and motivation Unconditional positive regard Building the system What s Important? Challenging our preconceived ideas Consistency in practice Documenting the need for treatment